http://upload.orthobullets.com/topic/4029/images/triplane ap_moved.jpg
http://upload.orthobullets.com/topic/4029/images/ossification pattern.jpg
http://upload.orthobullets.com/topic/4029/images/preopap.jpg
http://upload.orthobullets.com/topic/4029/images/preoplat.jpg
http://upload.orthobullets.com/topic/4029/images/ctscan.jpg
http://upload.orthobullets.com/topic/4029/images/postop.jpg
Introduction
  • A complex SH IV fracture pattern with components in all three planes
    • triplane fractures may be 2, 3, or 4 part fractures
      • epiphysis fractured in sagittal plane (same as tillaux fracture) and therefore is seen on the AP radiograph
      • physis separated in axial plane 
      • metaphysis fractured in coronal plane and therefore is seen on the lateral radiograph
  • Epidemiology
    • most common in ages 12-15 years
      • juvenile ankle physis ossifies in specific order, which leads to transitional fractures such as triplane and tillaux fractures
      • distal tibia physis order of ossification
        • central > medial > lateral 
  • Mechanism
    • usually result of ankle external rotation similar to tillaux fractures
Presentation
  • Symptoms
    • ankle pain, inability to bear weight
  • Physical exam
    • swelling, focal tenderness
Imaging
  • Radiographs
    • AP radiograph shows Salter-Harris III 
    • lateral radiograph shows Salter-Harris II 
  • CT scan 
    • usually required to delineate fracture pattern and access articular congruity
    • fracture involvement seen in all 3 planes 
Treatment
  • Nonoperative
    • cast immobilization
      • indications
        • < 2 mm displacement
  • Operative
    • CRPP vs ORIF
      • indications
        • > 2 mm displacement
      • techniques
        • epiphyseal screw placed parallel to physis 
        • arthroscopic aided reduction can be used
Complications
  • Ankle pain and degeneration
    • articular step-off >2mm
 

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Questions (1)

(OBQ06.160) Figures A and B show an AP and lateral radiographs of a 15-year old boy who injured his ankle after skateboarding. What is the mechanism of injury with this type of fracture? Review Topic

QID:346
FIGURES:
1

supination - adduction

8%

(102/1236)

2

external rotation

77%

(950/1236)

3

internal rotation

2%

(30/1236)

4

pronation - abduction

7%

(89/1236)

5

axial load

5%

(59/1236)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

The fracture shown is a triplane ankle fracture which is an external rotation injury that occurs in patients during early adolescence as described by Spiegel et al in a retrospective review of 237 cases. Kay et al has a nice review of pediatric ankle fractures. CT scans are usually obtained for these fractures and treatment depends on the amount of displacement.


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